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Light at the End of the Tunnel

Posted by Frederick Wasti
Oct 30 2014

If you're at least a more-or-less regular reader of this blog, you must be all too familiar with the above graph. After all, it shows how the total number of white blood cells in my blood has varied over time, and it is clear that it hasn't varied much at all "in many moons" now. So, at first glance, it's just another "Total White Blood Cells since the start of the clinical trial" graph.

Similarly, the "% Lymphocytes & Neutrophils since the start of the trial" graph above should look very familiar, too, and, once again, it can be seen that the percentages of neutrophils and lymphocytes haven't varied very much in a long time, either. However, if you look just a little more closely, at either graph, you might notice that I have added a new "milestone" vertical line over to the right end of each graph, labeled "Part C Ends".

Yes, INDEED, Part C is about to end, and (on November 10th, 2014) my very next visit to Dana-Farber Cancer Institute will be my last visit there as a participant in the clinical trial that I joined about 2 and 1/2 years ago. So, I can now easily see "light at the end of the tunnel".

Actually, the light at the end of the 2-and-1/2-year tunnel has been visible for a while, and it has been lately looking brighter and brighter,...

...but maybe not clearer and clearer -- you see, the light has also brought some uncertainty, as well.

If you think about it for just a bit, you maybe can realize that, during the trial, things were either supposed to improve greatly (back in the earlier months of the trial), or to remain the same (throughout most of the trial) -- and that's exactly what has happened.

However, the light at the end can also show a slight down side, too -- that is, it can offer some uncertainty - ...


You see, after I was diagnosed, but before I started treatment in this clinical trial, I was in the limbo of a (not long enough) "Watch and Wait" period.

During that W&W period, changes in my blood did take place, slowly at first, and then a little more rapidly toward the end of it,...

...but, in a sense, I still had a light at the end of that W&W "tunnel", which was this clinical trial, which - I was convinced - would offer a dramatic improvement in my condition.

However, now that I am nearing the end of the clinical trial, even as I am aware that it has fully lived up to my expectations,...

I will shortly be entering a new phase, during which I really do ~not~ know just what will happen, or when.

Presumably, I will see no signs of disease for a while (and hopefully it will be a ~long~ while), but that is an uncertainty.

Life is full of uncertainty, of course, but I am merely trying to explain how, in this case, the brightening light at the end of the tunnel can also be just a bit unsettling.

Oh, well -- I guess that this anxiety that I am trying to describe to you is likely just a normal reaction to having to enter a new phase in my life.

~SO~, considering that I am indeed ~fortunate~ to be able to reach that light at the end of the tunnel,...

...I really should concentrate on ~rejoicing~, as I enter my new future,...


Categories: General, Leukemia

August Update

Posted by Frederick Wasti
Aug 26 2014

What I said for the "July Update" is still basically true, although recently I have had a difficult time dealing with some arthritic conditions, the worst of which have (thankfully) been resolved.

So, without further ado, here are the usual "boring" charts:

As you can see from the above, the total white cells are still well within the "normal" range, while the lymphocytes are still (intentionally) quite low (seemingly almost non-existent), so the neutrophils get to be quite numerous.

Finally, I am pleased to report that I am still on track for finishing this clinical trial in November, which should make for quite a transition. :-)

Categories: General, Leukemia

July Update

Posted by Frederick Wasti
Jul 31 2014

Medically, things are still going "boringly" quite well. I still have fatigue, the level of which does vary from day to day, and it is (I hope) likely due to the concoction of meds that I take (some every day, some every two weeks, and some every eight weeks). "The numbers" still look good -- the total white cell count continues to be kept (artificially) "normal"...

... while the lymphocytes are still being kept intentionally suppressed, allowing the neutrophils to be plentiful...


So, as I said, things are still going "boringly" well (especially when the alternatives are considered)... :-)

Categories: General, Leukemia

My June 8th Whale Watch, Part 2

Posted by Frederick Wasti
Jun 15 2014

Note: This is only "Part 2" of my pictures and descriptions of a whale watch I attended on June 8th, 2014.

I am documenting the trip (which may or may not be my only trip for 2014) here in this blog. However, it will appear as two entries, the previous "My June 8th Whale Watch, Part 1", and this "My June 8th Whale Watch, Part 2", due to the number of photos included.

If you happen to be reading this "Part 2" entry (posted for 6/15/14) first, please stop and instead look first at the "Part 1" entry (posted for 6/14/14), since the images and captions appear in simple chronological order (divided approximately in half), and neither entry ("Part 1" or "Part 2") stands on its own.

I have appended the latest blood test results to the end of this "Part 2" entry.

The story now continues (from where "Part 1" left off)...

A baleen whale's upper jaw is smaller than its lower jaw, and the difference is most pronounced when the whale has its mouth open while feeding:

Each baleen plate (which grows continuously during the whale's life, much like a fingernail), is frayed on the inside surface, so that, while the plates resemble the "teeth" (so to speak) of a person's hair comb when viewed from the outside of the mouth, they actually form a complex filter of hair-like bristles on the inside of the upper jaw:

The pink ridge you can see inside the upper jaw here is the "hard palate" on the roof of the mouth:

In this photo, two humpbacks have surfaced together. Such cooperative feeding is often seen among some whales on many whale watch trips, while other whales can also be seen feeding concurrently, but individually, nearby:

[I should point out that we are not quite as close to these whales as many of these photos might make it seem. We were certainly not far from these very cooperative whales, but these photos were taken with a telephoto lens (with an effective 35mm focal length of 450mm), and most of the processed images have also been cropped as well.]

Now, in this series of photos,...

...one whale of a feeding pair...

...ends up turning upside down in the process of scooping up the fish:

For feeding whales, "table manners don't count". :-)

I should point out that, while feeding takes up several hours each day for these whales, they also do have rest periods, play periods, and travel periods, and not every whale watch trip is the same as this one -- they vary so much that there may not really be such a thing as a "typical" whale watch trip:

The whales we saw on this trip were primarily feeding, but it is also gratifying to see playfully active whales at times, or "friendly" whales (purposefully "visiting" the whale watch boat, circling around the boat and/or going from side to side under the boat). Every whale watch trip is indeed different:

Furthermore, I should point out that these whales - humpback whales - are generally the most active, most friendly, and otherwise most cooperative of the larger whale species, so that Massachusetts whale watches tend to concentrate on encounters with humpbacks:

I should also point out that whale watching is regulated by the U.S. government (with mostly common-sense rules to follow), and, in general, most commercial whale watch boats are well-behaved around the whales:

However, there is a problem with a small minority of the smaller, private boats that seek to watch whales -- most private boats are very careful around the whales, but some of them, mostly (I hope) unintentionally, can sometimes act in ways that endanger humans and whales alike:

Unfortunately, most of the small private boats are not aware of the regulations (although many - but not all - still behave intelligently and appropriately), and enforcement is generally lacking (that is to say that the U.S. Coast Guard does not devote resources to watching the boats near the whales):

Commercial whale watching in Massachusetts waters has been going on since 1975, when one charter fishing boat captain from Provincetown noticed that fisherman often stopped fishing to watch whales whenever they appeared, and he realized that dedicated whale watch trips might attract people who just wanted to see whales:

One of the special aspects of watching humpback whales is that individual whales are generally quite recognizable (something that is not true in nearly all other species). For example, these are the flukes of a female humpback named "Salt":

Salt has been seen every year in Massachusetts waters since 1975. As you can see, she has been seen once again here this year, with her 13th known calf by her side. (Humpbacks - and, in fact, most baleen whales - give birth most commonly every two or three years or so):

One of these two calves is Salt's calf. While Salt and the other mother (named "Perseid") were feeding nearby, the two calves approached our boat to (seemingly) say "Hallo". [I should point out that this photo and the next three seem overly cropped, but that was only because the whales were "too close" to my camera's telephoto lens.]

Here, one of the calves rolled on its side and put one of its long white flippers (or pectoral fins) into the air -- needless to say, this was enjoyed immensely by everyone on the boat. It seemed at that point very much as if we were "babysitting" the two calves while their mothers were busy feeding. :-)

All of a sudden, Salt, Perseid, and another adult humpback came up in unison, with their mouths wide open, right next to the boat (in fact, too close for me to get all three whales fully into the same photo). Salt is the whale in the upper right corner:

Here is Salt again, still with her mouth open (but starting to close), while one of the other two has already leveled off at the bottom of the photo:

As you can see, humpback whales can be very cooperative for whale watching. Throughout all of this encounter with humpbacks, our boat remained mostly motionless, moving very, very slowly from one group to another only occasionally:

There are other species that can also be seen here in Massachusetts. For example, after leaving the humpbacks (which were the whales located farthest from our port of Plymouth on this particular trip), we started back, and came upon a group of three finback whales, perhaps a mile or two from the beaches near the tip of Cape Cod:

The three finbacks seemed to be feeding as a group of two and as an individual. However, we also discovered that these finbacks (members of the second largest species in the world, larger than humpbacks) were accompanied by several dozen Atlantic white-sided dolphins:

It is not unusual to see such dolphins in the company of feeding whales (or sometimes in the company of traveling whales). [I do suspect that the dolphins are usually a nuisance to the whales, though.]

Atlantic white-sided dolphins are the most common dolphin species seen in Massachusetts waters north of Cape Cod. (In the warmer waters south of Cape Cod, other dolphins are often seen as frequently as is this species.)

Finbacks are faster than humpbacks, and, statistically, are less likely to come up close to a stationary boat while they are feeding. (It does happen sometimes, but not on this trip.)

The seemingly more playful dolphins did come over close to us on occasion, but they mostly seemed to continue feeding along with the finbacks:

It is quite easy here to see why these dolphins are called "white-sided", although the white stripe on their sides turns into a tan stripe closer to the tail:

All in all, I did have a successful whale watch, and I wanted to share it with you. Thanks for "watching". :-)

On the day after the whale watch, I had a treatment day at Dana-Farber in Boston. The blood tests results were "more of the same", i.e., about the same as they've been for many months now.

For example, my total white cells count continues to hover well within the normal range (of roughly 4,000 to 9,000 white cells per microliter):


In addition, my lymphocyte count remains very, very low (which is what is supposed to happen because of my treatment), while my neutrophil count is quite high (because neutrophil production in my bone marrow is not being suppressed by excessive lymphocyte production):


I know that the above two graphs have looked pretty boring for many months now, but that is what is desired. So, boring or not, what's not to like? :-)

Categories: General, Leukemia

My June 8th Whale Watch, Part 1

Posted by Frederick Wasti
Jun 14 2014

I was able to go on a whale watch on June 8th, 2014. I was aboard the "Tails of the Sea" (Capt. John Boats, of Plymouth, Massachusetts) as a "civilian" - i.e., as a passenger, and not as the trip's naturalist (since I am retired from my job of having been a whale watch naturalist for Capt. John Boats for 30 years).

I am documenting the trip (which may or may not be my only trip for 2014) here in this blog. However, it will appear as two entries, in this "My June 8th Whale Watch, Part 1" and then in the "My June 8th Whale Watch, Part 2", due to the number of photos included.

If you are reading this "Part 1" entry (posted for 6/14/14) first, please do also look at the "Part 2" entry (posted for 6/15/14), since the images and captions appear in simple chronological order (divided approximately in half), and neither entry ("Part 1" or "Part 2") stands on its own.

I have appended my latest blood test results to the end of the "Part 2" entry.

The story begins...

The first marine mammals we came across on this beautiful day offshore were not actually cetaceans (the term for whales, dolphins, and porpoises), but were pinnipeds (the term for seals, sea lions, and walruses) known as gray seals:


This group (of about a dozen) were swimming along together quite rapidly, but seemed to slow up just a bit to take a brief look at us. However, as their brief curiosity seemed to fade,...


...they resumed their journey. [There are two species of seals typically seen in Massachusetts waters, the larger gray seals, shown here, and the smaller harbor seals.]


We next saw a couple of minke whales (the smallest species of the baleen whales), but we didn't spend time trying to stay with them, instead choosing to continue on in order to find some of their larger relatives. Here is one of the first humpback whales that we found:


As you can see, humpback whales are often very approachable (and, in fact, they sometimes even approach boats). The "tail fins" of a whale are known as their "flukes":


What we then spent a while watching was a group of a couple dozen humpback whales, most of whom were involved in feeding on schools of small fish at the time. (Humpbacks typically spend a few hours feeding each day.)


Generally, feeding humpbacks tend to ignore nearby boats (although sometimes, on rare occasions, they can be observed seemingly driving their prey toward the physical barrier of a boat's hull):


Notice the bird here resting briefly while standing on the upper jaw of this whale. :-)


Although some baleen whales, such as the right whale and the bowhead whale, feed on swarms of tiny plankton, most baleen whales (such as this humpback) feed on highly mobile prey, and feeding must thus be a very active behavior:


While feeding, whales often attract large numbers of fish-eating birds (such as these juvenile and adult herring gulls), that benefit from the large number of small fish that are driven towards the surface barrier by the whales. (Notice another bird "resting" briefly on the tip of this whale's upper jaw.)


Here you can get a good view of the whale's "blowholes" (nostrils) and its upper jaw. Those rows of bumps that you see on the jaw are likely functional,...


...since each bump has a single hair extending from it, much like a "whisker", and these hairs may help the whale detect water movements of fleeing prey animals in the vicinity of the mouth:


The "feeding frenzy" of active birds that gather around and above feeding whales is even used by whale watch boats trying t find whales on a foggy day,...


...since the birds will show up more readily - and more constantly - than a whale on a boat's radar, helping to lead a whale watch boat towards a whale that cannot be seen (until close) in heavy fog by eyes alone:


I have used the term "baleen whale" previously, and so it's about time that I explained what baleen is. Note in this photo the comb-like structure hanging down from the upper jaw of this whale - that is its baleen:


There are two major groups of whales, baleen whales and toothed whales. All of the larger whale species except for one - the sperm whale - have no teeth at all, and instead have baleen plates in their upper jaws:


Baleen is not bony, as teeth (sort of) seem to be, but instead consists of a series of flexible plates made of keratin, a structural protein found most commonly in a mammal's skin, hair/fur, and nails/claws:


It should not be too surprising, then, that baleen is also made of keratin, because baleen plates grow down from the skin tissue of a baleen whale's gums inside the outer edges of its upper jaw:


While the plankton-feeding right whales and bowhead whales have very long baleen plates located in two groups, just on either side of the mouth (with no baleen in front), most baleen whales have baleen that grows from both the front and the two sides of the mouth,...

...although the baleen plates are always shorter in front and longer toward the sides:


The "toothed whales", by the way, include the sperm whale, nearly all of the smaller whales, and all the dolphins and porpoises. However, this humpback whale is one of the larger baleen whales:


On a whale watch trip it is possible to see pelagic (open ocean) birds, in addition to coastal birds (such as all the gulls seen in many of the feeding pictures here). As an example, this is a sooty shearwater, a species which breeds on certain islands deep in the South Atlantic Ocean, but which "winters" during the warmer northern hemisphere months over the North Atlantic Ocean:


Unlike gulls (which return to land every day to rest), pelagic birds spend most of each year entirely over water, returning to land only once a year for breeding. (Note in this picture where the name "shearwater" comes from -- this bird's right wing tip is "shearing" the water as it flies along, something that happens fairly often.)


In this series of photos,...


...you can see a humpback...


...feeding with a technique...


...known as "kick-feeding",...


...where the percussive (and perhaps concussive) effects of slapping the water with its flukes apparently could either stun or at least confuse its prey:


There are a number of different feeding techniques that can be employed (and observed), apparently depending on the nature of the prey, and with individual differences in "style" between different individual whales. In any case, it should be noted that humpbacks do not feed by a mere passive straining of the water for fish.


To be continued (in "Part 2")...

Categories: General, Leukemia

Bicycle or Unicycle ???

Posted by Frederick Wasti
Apr 05 2014

Today's entry is about cycles - unicycles and bicycles, two words that nearly everyone should be familiar with.

The bicycle (or "bike") is probably the more familiar of the two vehicles for most people, since most of us have ridden one as a child (often first with, and then hopefully without "training wheels") and/or as an adult (most certainly without "training wheels", right?). On the other hand, the unicycle is something that most of us have (wisely) never even tried to ride, since it requires considerably greater balancing skills to do so.

The terms "unicycle" and "bicycle" are actually fairly modern words, both being used for the first time in the 19th Century (the bicycle was invented in the early 1800's and the unicycle in the later 1800's). However, the stem word that both terms share, "cycle", is much older -- it was derived from the Late Latin "cyclus", which in turn was derived from the Ancient Greek "kuklos", both meaning "wheel". The two prefixes "uni-" and "bi-" are from Latin, and, of course, indicate the number of wheels (or "cycles") on the vehicle, either one or two, respectively. [And, of course, there are also "tricycles", which have "tri-" (for "three" in Latin) "cycles" instead.]

The earliest bicycles that were in common use had two wheels of considerable difference in size (and they were probably not all that much easier to ride than unicycles):

Bicycles have evolved over time, of course, and some modern lightweight bikes have been optimized for great speed, either for individual racing,...

..., or for team racing,...

Another very different modern design is that of a "recumbent bike",...

..., which is supposedly easier on the hips, back, shoulders, and arms than a traditional bike. However, most bike riders settle for something a bit more mundane. A popular current design is what is known as a "hybrid bike", having tires a little "fatter" than the "skinny" tires of racing bikes, and usually also having "regular" handlebars (as opposed to the "drop handlebars" common on racing bikes). This hybrid bike,...

..., is quite similar to my own personal bike. Such hybrid bicycles are good for all-around biking, especially on pavement, but, of course, they represent compromises in design. For example, while the hybrid's tires are "fatter" than on a racing bike, giving better traction, greater stability, and a slightly more comfortable ride, with only a modest loss of speed, a hybrid's tires are not "fat" enough to be suitable on sand, such as is this "classic" bicycle,...

..., much like the one that I recently rode on to and from the beach in Florida. And, of course, there are "off-road" bikes, such as this one,...

..., that have extra-sturdy frames and wide "knobby" tires for traction and stability on very rough terrain.

As for unicycles, most of us are at least superficially familiar with basic unicycles (such as used by circus clowns, perhaps, or as seen on TV),...

..., but unicycles have also evolved in different ways, too. For example, here is a racing unicycle (not for the faint of heart),...

..., and here is a motorized unicycle, for the ultimate in maneuvering in heavy urban traffic,...

..., such as getting-to-Dana-Farber-on-a-Monday-morning rush-hour traffic. (Wear a safety helmet, though.)

Now, you might be wondering just why I am discussing bicycles and unicycles here. Well, please let me try to explain:

First, here is a quote from my clinical trial protocol: "Part C is a maximum of 26 cycles of 28 days. Ofatumumab will be given intravenously every other cycle. Alemtuzumab will be given as a subcutaneous injection every 14 days."

So, during Part C of the trial, each cycle is 28 days long, and there are two treatment days during each cycle, 14 days apart. Alemtuzumab (Campath) is given (by injection) on every treatment day. However, since Ofatumumab (Arzerra) is "given intravenously every other cycle", the 28-day cycles alternate between cycles where Ofatumumab is given and cycles where it is not.

Every treatment day starts (after some "waiting room time") with a blood draw, and certain blood test results have to be received back from the lab before any treatment for that day can be prescribed, which does involve about an hour or so of "waiting time". Currently, on every other treatment day (after some more "waiting room time"), I also have to see my nurse practitioner or my doctor for a brief check-up, which also involves some extra time as well. (For much of the trial, I had to meet with one of them on every treatment day, but the good news is that this requirement was eased a few months ago to just every other treatment day, since I seemed to be doing OK.) The Alemtuzumab injection itself takes very little time, but there is some "waiting room time" involved before I actually get into the infusion area for the injection. Nonetheless, on treatment days that do not involve an Ofatumumab infusion (which, in Part C, are three-fourths of the days), I tend to think of such days as "short days" (since they usually involve just a few hours of time).

Any treatment day that also involves Ofatumumab takes considerably more time than a "short day", since the drop-by-drop intravenous infusion of Ofa takes about four hours, and one of the pre-meds that have to be given before the infusion (Methylprednisolone) involves a drop-by-drop infusion itself, even before the Ofa can be infused. The good news with Ofa treatment days, which I think of as "long days", is that they make up only one-fourth of the treatment days, only once every other 28-day cycle.

So, following the description given in the clinical trial protocol, there are 26 cycles (taking 28 days, or almost one month, for each) in Part C. However, since only every other cycle involves a "long day", I've come to think of each cycle in Part C as having a length of 56 days (almost two months long), involving one "long day" followed by three "short days". So, when I see my doctor and he says something such as "Well, we're up to Cycle 16, and [...]", it tends to surprise me, since I have come to think of Part C as having only 13 cycles (because there are only 13 "long days"), and, in my mind, we'd only be "up to Cycle 8" on that day.

As a result, a person reading the clinical trial protocol literally might refer to a 56-day period of time in Part C as a "bicycle" (because it would be two cycles long), but I tend to think of such a 56-day period as making up only a single "unicycle". However, regardless of whether Part C is really comprised of 26 cycles of 28 days each, or can be thought of as 13 cycles of 56 days each, the ~really~ good news is that Part C should end for me in ~November~, when I will be graduated from this life-saving clinical trial into another (hopefully ~very~ long) W&W ("watch and wait") period...

Meanwhile, I'll be pedaling my "unicycle" just as fast as I can - <grin>.

In the meantime, my blood counts continue to be "pleasantly boring":

So, it does seem at least that I'm pedaling in the right direction...


Categories: General, Leukemia

No (New) News is Good News

Posted by Frederick Wasti
Mar 03 2014

Blood test results from today's visit to Dana-Farber Cancer Institute in Boston showed no significant change in what's going on in my blood:

So, "no news is good news", or, at least, "no (new) news is good news", as the expression (sort of) goes...

Categories: General, Leukemia

Boring is a Good Thing

Posted by Frederick Wasti
Jan 06 2014

Today's blood test results from my Campath treatment day at Dana-Farber (included on the graphs below) continue to be "boring".



However, in this context, "boring" is a good thing...

Categories: General, Leukemia

Band of Blood-ers (Leukocytes #3) [interim]

Posted by Frederick Wasti
Dec 28 2013

So as to not keep any longer anyone who may have attempted the little quiz from my last post ("Band in Boston (Leukocytes #2)") from being able to grade their answers, here are the correct answers:

1 =

2 =

3 =

4 =

5 =

I do apologize for not (yet) providing these answers along with a proper explanation for each of them - Sorry!

Categories: General, Leukemia

Band in Boston (Leukocytes #2)

Posted by Frederick Wasti
Nov 27 2013

[If you haven't yet seen my previous blog post, "And the Band Played On (Leukocytes #1)", please check it out first and then come back to this post, which is merely a continuation of it. Thanks.]

You might recall how my blood test results from 9/16 (from the Dana-Farber in Boston) looked, with their "odd" naming and counting of neutrophils -- well, here they are again, along with some more recent (and more "familiar" appearing) blood test results, as a comparison:

We saw, in my previous post, that the neutrophil count from 9/16, which (at first) seemed to be "missing", was indeed actually included, but that the neutrophils were (somehow) differentiated into Bands, Polys, and Metas. I still have to explain what Bands, Polys, and Metas represent, but first we have to go over how the five types of white cells are differentiated, and so that will be the subject of this post -- today you will see how we can visually tell the five leukocyte types apart.

[If you aren't familiar at all with the various types of blood cells, you might refer back to my post from 4/1/2012 on "Blood Cells 101".]

As mentioned in the last post, the five white cell types fall into two groups, "granulocytes" and "agranulocytes", the distinction being based upon whether the cells show specks or granules in the cytoplasm (i.e., the material within the cell that is outside the nucleus). Let's look at the granulocytes first:

If you look carefully at the above granulocyte drawings, you should notice visible reddish granules in the eosinophil and even more obvious bluish (or purplish) granules in the basophil, and perhaps, if you look really carefully, some faint, small reddish or pinkish granules in the neutrophil. (In contrast, the agranulocytes - lymphocytes and monocytes - do not show such granules in their cytoplasm.)

An erythrocyte (i.e., a red blood cell) is included in the above image to allow for estimating the size of the white cells. Since, when a blood smear is examined microscopically, the very numerous red cells will appear in every field of view, and since nearly all red cells are approximately the same size as each other, each red cell makes a useful "yardstick" for judging the relative sizes of white cells. You may have noticed above that the three granulocyte types are each somewhat larger than are red cells.

[This size estimation ability may not seem to be all that useful just yet, when looking at just the granulocytes, because each granulocyte is roughly the same size as every other granulocyte, but size estimation will seem to be more useful when we get to the agranulocytes, since lymphocytes are distinctly smaller than the granulocytes, while monocytes are often larger.]

Let's take a look specifically at the neutrophils first:

In the above microscopic image, there are four neutrophils. Note that they are distinctly larger than are the red cells, that their cytoplasm is "speckled" (i.e., granulated) (although not obviously so), and that their nuclei are multilobed (usually consisting of from two to five lobes, connected by thin filaments, not usually visible at this magnification). (You can also see that the more numerous red cells lack nuclei, and you should also be able to spot about a dozen or so very small platelets as well.)

Taking a closer look at another neutrophil, ...

... the small, faint, pinkish granules are (slightly) clearer, and the nuclear filaments can also be seen as well.

Of course, you already know that all these ~stained~ white cells no longer look white after staining, and it is, in fact, the nature of neutrophils and the stain that colors their granules that is the reason for their name. Blood stains generally are made of a mixture of several stains of varying pH values, and it is the ~neutral~ stain, and not the acidic or alkaline stains, that end up coloring their granules -- hence, they are called "neutro-phils" because they have an affinity for (or "love") the neutral stain in a blood stain mixture (the "phil" comes from the Greek word "philein", meaning "to love").

So, what do you have to remember about neutrophils, in order to be able to recognize them? Well, it really boils down to just three characteristics:

1. Neutrophils show faint reddish or pinkish granules in their cytoplasm.

2. Neutrophils show a multilobed nucleus (of two to five lobes). (In fact, if you spot a white cell with more than two lobes to its nucleus, it is likely to be a neutrophil.)

3. Neutrophils are "somewhat" larger (perhaps very roughly 1.5 to 2 times greater in diameter) than red cells, and are roughly the same size as eosinophils and basophils.

OK, let's take a look at eosinophils ("ee-oh-sin-oh-fills") next. Eosinophils are granulocytes that have (when stained) large reddish granules in their cytoplasm. Compared to the neutrophils, the granulation is much more obvious. Most of the time the nucleus in an eosinophil is bilobed (i.e., having two lobes) in appearance. Take a look at the following image, of two eosinophils and a neutrophil, to see how these two types of granulocytes compare in size, in granulation, and in nucleation:

By now, you're probably trying to figure out the etymology of the name "eosinophil". You already know that the "-phil" means "loving" -- it's just the "eosino-" part of the name that might be confusing -- it turns out that the granules of eosinophils have an affinity for a particular ~acidic~ stain with the name of ~Eosin~. [Eosinophils could also, because of this, be referred to as "acidophils" (and sometimes they are), but that's a considerably less common name for these particular white cells, for some inconsistent reason as of yet unbeknownst to me.]

Anyway, what do you have to remember about eosinophils, in order to be able to recognize them? Well, once again, there are just three characteristics to look for:

1. Eosinophils show fairly obvious reddish granules in their cytoplasm (redder and more distinct than the pinker and much smaller granules in neutrophils).

2. Eosinophils usually show a bilobed nucleus.

3. Eosinophils are "somewhat" larger (perhaps very roughly 1.5 to 2 times greater in diameter) than red cells, and are roughly the same size as neutrophils and basophils.

So, then we have the third type of granulocyte, the basophil, to consider:

Basophils are somewhat like eosinophils, except that the granules are more purplish or bluish, rather than more reddish, as in eosinophils. Sometimes this difference may not be overly obvious, though, since the reddish granule color of eosinophils can sometimes seem a bit on the purplish side, while the bluish granule color of basophils can also tend toward purplish. However, sometimes the basophils can also be seen to have granules that are somewhat larger in size, or "coarser" in appearance, than those seen in eosinophils.

In the image above, the two basophils seem not too similar in appearance. Part of this is because the granules do differ in color somewhat between the two cells, but part of the difference is also because the nucleus is closer to the viewer in the upper cell, while the nucleus is farther from the viewer in the lower cell, so that, in the upper cell, the nucleus is hiding many of the granules behind it, while, in the bottom cell, the granules are doing a good job at hiding the nucleus behind them.

Basophils get their name because they and up reacting to the ~basic~ (or alkaline) stain in a typical blood stain mixture.

OK, so what do you have to remember about basophils, in order to be able to recognize them? Well, once again, there are just three characteristics to look for:

1. Basophils usually show obvious bluish or purplish granules in their cytoplasm (sometimes appearing a bit more pronounced than the granules of eosinophils, but always ~much~ more obvious than the faint granules of neutrophils).

2. Basophils usually show a bilobed or U-shaped nucleus.

3. Basophils are "somewhat" larger (perhaps very roughly 1.5 to 2 times greater in diameter) than red cells, and are roughly the same size as neutrophils and eosinophils.

Let's now turn our attention to the agranulocytes (a.k.a., the non-granulocytes), which include the lymphocytes and monocytes:

First, it should be clear (so to speak) that, as the name suggests, there are ~no~ granules in the cytoplasm of the ~non~-granulocytes (i.e., the agranulocytes). Second, it is apparent that there are size differences to be considered with the agranulocytes. And, finally, it should be noted that agranulocytes have a relatively simple nucleus, generally U-shaped or even cup-shaped in appearance.

Taking a look at lymphocytes first, ...

... it can be seen that lymphocytes are quite a bit smaller than any of the other white cells, with a size generally roughly the same as that of the red cells (or a bit larger). There is not too much cytoplasm to look at, because the nucleus of a lymphocyte, approximately round or oval in shape, seems to fill up most of the inside of the cell -- however, there are still no granules to be seen in the limited amount of cytoplasm that is visible.

So, to most easily distinguish a lymphocyte, look for these three characteristics:

1. Lymphocytes do not show much cytoplasm, but what cytoplasm they do show is relatively clear, with no obvious granules.

2. Lymphocytes show a round or oval nucleus that seems to almost fills the cell.

3. Lymphocytes are easily the smallest of the white cells, being very close to the red cells in size.

In contrast, monocytes, ...

... the other type of agranulocytes, are generally the largest of all the white cells, with a diameter of often approximately twice that of red blood cells. [The Golgi apparatus shown in the above monocytes, which is involved with cell secretion, is not usually too visible in most blood smear preparations.]

The nucleus of a monocyte is quite large (although it does not come close to filling up such a large cell) and is usually U-shaped or cup-shaped in appearance, although sometimes it can be irregular (even "blobby") in shape.

There are no granules in a monocyte's cytoplasm -- although the cytoplasm may not be totally transparent, ...

... there still is a lack of any colored granules to be seen in it.

Therefore, the three main characteristics to look for in trying to distinguish a monocyte are:

1. Monocytes, being agranulocytes, lack any visible colored granules in their cytoplasm.

2. Monocytes show a large nucleus that is U-shaped, cup-shaped, or irregular in shape.

3. Monocytes are significantly larger than any other white cells, often having a diameter twice (or even more than twice) that of the red blood cell "yardsticks".

Now, please do not be intimidated by all these characteristics. First, I have tried to limit the similarities and differences to just three characteristics for each of the five types of white cells -- you really have to look for only the granulation (if any) in the cytoplasm, the shape of the nucleus, and the relative size of the cell. It's that "simple". Really. Besides, you really don't have to be "good" at distinguishing these cell types -- I am merely trying to ~acquaint~ you with the morphology of the types of leukocytes. So, no pressure, right?

Well, er, um, maybe just a wee bit of pressure: (<grin>) How about a little quiz, where you can prove (to ~yourself~) that you can indeed do a pretty good job at telling one white cell type from another? You can grade it yourself, and you can score it on a "pass-pass" basis. And it's an "open book" quiz (or an "open blog" quiz anyway - you can look at all the characteristics provided above. So, just how hard can it be, right? Eh?

Just to help you succeed more easily, I'll even summarize the most useful things to look for before we begin, OK?

1. If the nucleus shows three or more lobes, it's likely to be a neutrophil.

2. If the cytoplasm shows obvious reddish granules, it's likely to be an eosinophil.

3. If the cytoplasm shows obvious bluish granules, it's likely to be a basophil.

4. If the cell is a very small cell, similar to a red cell in size, it's likely to be a lymphocyte.

5. If the nucleus seems to fill up most of the cell, leaving room for very little cytoplasm, it's likely to be a lymphocyte.

6. If the cell is a very large cell, at least twice as wide as a red cell, it's likely to be a monocyte.

Finally, I'll provide one more hint for the quiz: I'm going to show five images, and they are for the five types of white cells, one image for each type. Therefore, you might be able to come up with the answer for a "tougher" image by "the process of elimination". OK? (The bad news is that, if you guess one incorrectly, and are using "the process of elimination", you probably have at least two of 'em wrong - <grin>.) Of course, "in the real world", in a blood lab, the technicians can't use "the process of elimination" when counting cells.

So, grab a scrap of paper (perhaps the back of an envelope from a bill that you weren't going to pay anyhow, say), number it from 1 to 5, and try to put an 'N', an 'E', a 'B', a 'L', or an 'M' for each cell type next to each number. (See? -- you don't even have to spell out the names -- easy, eh?)

Ready? Here goes -- here are your "unknown" white cell types:

I'll provide the answers in the next blog entry -- so, please stay tuned. (And don't lose your "scrap of paper".)

[Please note: I did intend to include a little information on the background for the expression "Banned in Boston" as part of this entry, but, in order to get this blog entry "out the door", I will delay writing that until probably sometime after posting the third issue of this series (which will include the answers to today's little quiz), entitled "Band of Blood-ers (Leukocytes #3)" - as I said very recently, "please stay tuned".]

Categories: General, Leukemia